Archive | Rural-Proofing

The Royal College of Physicians and Surgeons of Glasgow is pleased to announce a provisional programme for the Safety and Sustainability in Rural General Surgery Conference on 30 November and the morning of 1 December 2017. This conference will bring together many of Scotland’s current surgical trainees with a long-established network of remote and rural surgeons, the Viking Surgeons’ Club, in an exciting and unique event.

The conference will explore the current reality of Scottish rural surgical service provision, discuss the international remote healthcare experience, and offer updates into the management of surgical subspecialty emergencies in a rural context. We welcome delegates from around the world who have an interest in rural healthcare and the challenges therein.

Title: Safety and Sustainability in Rural General Surgery: The Viking Surgeons’ Conference 2017

Date: November 30 and December 1 2017

Venue: The Royal College of Physicians and Surgeons of Glasgow, 232 – 242 St Vincent Street, Glasgow, G2 5RJ

Dr Patrick Byrne, consultant at the Belford Hospital in Fort William, was involved in hosting a visit from a delegation from the Philipines. This article featured in Lochaber Life Magazine earlier this month. It has been reproduced here with the kind permission of Iain Ferguson of the Write Image (picture credits to Iain too).

PHILIPPINE VISITORS TO BELFORD

Dr Patrick Byrne

The Belford Hospital continues to punch above its weight on the national and international stage, welcoming a delegation from the Philippines a few weeks ago. The visit was part of a week-long study tour to the UK by Presidents and delegates from the Philippine Royal Colleges of Physicians, Surgeons, Paediatricians and Obstetricians and Gynaecologists, alongside officials from the Philippine Ministry of Health.

Teaching & training for most healthcare providers in the Philippines tends to be concentrated in the largest hospitals in cities, ignoring the district and rural locations. This is in contrast to the UK where every hospital has a role to play and sometimes the best experiences and training is to be found in the smallest facilities, where one-to-one supervision from consultant teachers is often the norm, not the exception. The purpose of their study tour was to learn from UK practices, specifically how supporting and investing in rural hospitals leads to a more efficient healthcare system across the region, and the country.

Led by the immediate Past President of the Royal College of Surgeons, Mr Ian Ritchie (who has family ties to Corpach), the delegates specifically requested to see an example of good training in a small hospital of approximately 100 beds. Mr Ritchie replied, “I can bring you to a 34-bed hospital where training and patient care is not just good, but excellent”. The importance of this visit, was underlined by the presence of the most senior NHSH personnel – Prof Elaine Mead (Chief Executive Officer), Mrs Gill McVicar MBE (Director of Operations) and Dr Emma Watson (Director of Medical Education).

Each, in turn, reiterated the importance of consultant-led services and training at Belford Hospital, both now and going forward. However, it was Miss Alison Bradley, a former Belford trainee, now a senior surgical registrar in Glasgow, who captivated and inspired everybody, proving that rurality is no impediment to ambition; quite the opposite, in fact, as she explained the details of her PhD research into pancreatic cancer.

Mr Ritchie said, “It was very clear to all who visited that numbers of beds is not an indicator of good training, it is that key relationship between a trainer and a trainee which, in Fort William, you all demonstrate to a very high degree. The high point was certainly the Belford.” In her letter of thanks, on behalf of the College of Paediatrics, Dr Cynthia Daniel echoed this, adding “I am certain with you and the rest who share the same passion for training and service, Belford Hospital should be safe for the next 150 years and beyond”.

Charged with the responsibility of overseeing and driving a wide range of activities around supporting ‘rural generalism’ the post offers a chance to provide more co-ordinated leadership across domains, regions and disciplines to make rural health strategy more cohesive in Australia.

Professor Paul Worley has been appointed as the first Rural Health Commissioner and this move has been widely welcomed across the rural health community. He brings an impressive portfolio of experience to the post, including in clinical, academic, educational and strategic development aspects of rural health. You can watch Dr David Gillespie MP announce the post, and Prof Worley outline some of his visions for the future (at 5min 55s), in the video below.

Twitter and other social networks – including the WONCA Working Party on Rural Health international email list – have been buzzing with positivity about the new post, and it is likely that this approach might pave the way for similar developments in other countries.

In Scotland, we are watching developments with interest. Rural medicine and health services are of significant importance in Scotland’s National Health Service – 98% of Scotland’s land mass is rural, and 18% of Scotland’s population live in a rural area, with many more flocking to rural areas during holidays. And yet despite considerable aspects of medical care being delivered by GPs and primary care teams, within community hospitals, A&E units and facilities outwith the usual remit of GPs, there continues to be relatively little in the way of co-ordinated clinical governance and strategic unity to link rural and isolated practitioners together. These services provided by rural GPs remain considered to be on the ‘fringes’ of general medical practice. Therefore the opportunities created by appointing an experienced individual to provide leadership, stimulate innovation and inspire positive approaches, are sorely needed in areas other than Australia.

Having met Paul at the WONCA World Rural Health conference in Cairns this year, I’m delighted to hear this news and inspired to think that this is a situation to watch closely. I have little doubt that we will be reflecting that Scotland could benefit from a similar approach in the near future.

Well done Australia, and all the folks involved in making this happen. These are exciting times.

This year, the Rural GP Association of Scotland has once again run its student conference scholarship programme. This is a significant investment for RGPAS, which uses money raised into its Educational Trust fund to support these scholarships. The scholarships offer heavily-subsidised tickets to enable undergraduate students in the UK to attend and participate in the annual RGPAS conference.

To apply, students were asked to submit a 60 second sound or video clip explaining their Bright Idea for Rural Practice. We are delighted to feature the winning entries below.

A number of these will be selected for PechaKucha-style presentation at our conference in November. You can read more about the scholarships here, and also a great write-up of last year’s conference by one of the scholarship holders then, Catherine Lawrence from Hull & York Medical School.

There is still time to sign up to the conference, which takes place from 2-4 November 2017 in Inverness. £130 for GPs or £65 for trainees gets you two-and-a-half days of quality CPD, along with a conference dinner (and wine). It’s a great way to catch up with like-minded colleagues, and hear updates on clinical and non-clinical topics that are relevant to rural practice in Scotland.

Well done to all our scholarship winners. We look forward to meeting you in Inverness!

This year, conference registrations should be made online. Until September 1st, registration will be restricted for current RGPAS members. After September 1st, registration will be open to all.

The cost of conference registration is £130, which includes catering (including Thursday lunch for RGPAS members attending the morning event), the conference dinner and wine on the Thursday evening. There are no single-day tickets and we hope that this is seen as excellent value for a 2.5-3 day conference.

Trainees can register for £65 (half price), and students who are successful in achieving a student scholarship will be asked to pay a nominal £10 registration fee.

Accommodation should be booked directly with the Craigmonie Hotel (01463 231 649) – unless you wish to stay elsewhere – and special rates are available on mentioning that you are attending the RGPAS conference.

Never have I been to a conference so friendly, so relaxed, and so full of life.

Programme

Thursday 2nd November 2017

This year, an RGPAS Members-Only meeting will be held on Thursday morning, to which all RGPAS members are invited. Lunch will be served to attending members after this session, following which the main conference will open.

Unfortunately Dr Hal Maxwell is no longer able to attend the conference, and our EMRS colleagues have had to pull out of the programme due to work pressures, therefore the programme for Friday and Saturday mornings has been rejigged, with further changes to follow. Delegates will be updated with further details once available.

Saturday 4th November

0930Looking Forward

(Updated: 22/10/17) In replacement of the EMRS clinical update session, we are delighted to run a session dedicated to GP mentoring, dealing with the stresses of practice, and steps to developing a peer-support or co-mentoring network within RGPAS. We will also be exploring other ‘next steps’ for RGPAS too. Full details about this session will be released very soon.

Clinical considerations and ethical deliberations from a rural Caribbean clinic

Dr Josie Reynolds recently contacted RuralGP.com to offer to write about her experiences and observations from rural Jamaica. We’re delighted to feature the first of these articles here…

As doctors, we are most comfortable with our diagnoses when we have investigative results to confirm them. This is especially true for those trained in high-income countries, as more and more sophisticated laboratory tests and imaging have become part of everyday practice.

But in rural, remote settings, particularly those of low and middle income countries, the practicality and cost of diagnostic testing can become a barrier to treatment. This barrier is intensified in the management of sexually transmitted infections by the taboo and stigma that surround these conditions.

Because of this it has been argued that a syndromic approach to STI management can be more appropriate to tackle the burden of disease. Syndromic management of STIs works by grouping symptoms and signs of disease into syndromes and treating based on the most common causative pathogen(s), e.g. vaginal discharge syndrome, lower abdominal pain and male urethritis syndrome.

This practical approach in the most resource poor environments can help to tackle high burden of disease, therefore reducing significant morbidity, infertility and increasing spread of infection. In these settings there is a strong argument for forgoing the lab tests and treating empirically.

But what about those settings that fall somewhere in the middle?

At what point is it more appropriate to treat following laboratory testing?

Are there any markers that indicate the tip of balance in favour of a laboratory-based approach?

Picture a rural Caribbean health clinic. The mountainous community can seem remote based on the terrible conditions of the roads, but in fact as the crow flies there is only 10 miles to the capital city. There is also fairly regular transport by bus to the city Mon – Sat, and a public run clinic in town which provides free STI testing and treatment (all be it slow).

Community members, however, have very little disposable income and primarily lead subsistence lifestyles. With this in mind, working as a primary care physician at the clinic, I was not keen to send people away without treatment in case they did not go to get testing & treatment and the infection continued to spread. Syndromic management, therefore, seemed the way to go…

But the more I thought about syndromic management – STI management without any laboratory testing – the more negative implications I could think of:

Contact tracing – this is still possible, but do you treat all sexual contacts even if symptom free? This could expose numerous people to the risk of unnecessary medications when there is no guarantee that they have the disease.

Missing concomitant STIs e.g. HIV – it’s not uncommon for STIs to come in pairs and symptoms are frequently vague or non-existent. Treating syndromically without testing misses the opportunity to pick up some of the more serious infections that may be present simultaneously.

Contributing to antibiotic resistance – as one of the biggest threats to modern medicine, antibiotic resistance cannot be ignored. Whilst syndromic management may be the pragmatic approach, the greater picture needs to be considered.

Relaxed approach – could syndromic management give patients the impression that STIs are not very serious as no testing is required? Could this apparently relaxed approach translate into less incentive to prevent reinfection?

The subtle symptoms – for the barn-door cases, where signs & symptoms are clear and fit neatly into the box, this approach is straight-forward. But what about the grey areas? Or the patients which don’t follow the usual pattern?

Impact on doctor-patient relationship – with a less evidence-based approach and therefore greater risk of treatment failure, is there a danger of loss of trust or breakdown of relationship between the healthcare provider and patient?

Reliable statistics – guidelines for syndromic management often mention adding in treatment for certain infections, e.g. gonorrhoea, if there are high levels in the region. However, in low-middle income settings, the epidemiological data is less likely to be complete and therefore recorded levels may be misleading.

I found myself in a struggling health system, but provisions were not non-existent – should I accept the flaws of the approach and treat syndromically or encourage patients to overcome the barriers and receive a better standard of care overall?

I realised too that part of my reserve for syndromic management linked into a deeper notion: by accepting syndromic management as routine are we reinforcing the idea that disadvantaged people deserve second rate healthcare?

Or perhaps my scientific-based training was blinding me to the benefits of syndromic management? Was my personal desire to get to the bottom of the cause preventing me from putting the important things first?

Either way, it appears to me that a more sophisticated set of guidelines is required from the Global Health Sector to reflect the variations in development of health systems worldwide, rather than a binary choice which may work for some, but not for all.

What do you think? What would you do in a similar situation? Which factors would tip the balance in your decision?

RuralGP.com has just received this request from Elizabeth, who is seeking contributions to research that she is carrying out into the needs of remote & rural practice in Scotland. If you are able to assist, please contact Elizabeth directly…

My name is Elizabeth Lemmon, I am a PhD student based at the University of Stirling and currently undertaking an internship at the Scottish Government within the Health and Social Care Analysis Team. The aim of the internship is to carry out some research into remote and rural general practice in Scotland in an attempt to better characterise them in terms of their activities and the challenges they face. I’m currently pulling together data which are publicly available on general practices to improve the evidence base and identify where further data analysis are needed.

I am contacting you to ask if anyone would be interested in sharing their experiences within remote and rural general practice and highlight any areas which you feel are priorities or which need further research?

I understand that there is currently work taking place within the Scottish Government on the Primary Care Evidence Collaborative which is developing a 10-year evaluation framework for primary care transformation. The work I will be doing during my internship on remote and rural practices will help to identify priorities for data, research and analysis and ensure that rural issues are included.

Back in March, the Rural GP Association of Scotland (RGPAS) launched a range of guidance designed to make rural practice in Scotland more accessible to lesbian, gay, bisexual, transgender (LGBTQ+) patients.

At the annual RGPAS Conference last year, held in Inverness, we were delighted to welcome Dr Thom O’Neill to talk about LGBTQ+ inequalities in rural areas, and some of the practical ways that as GPs we can reduce barriers to healthcare.

Thom’s presentation stimulated a lot of discussion, and led to a project whereby he worked with RGPAS to develop factsheets, posters and other materials to help rural GP practices ensure that their services are welcoming to LGBTQ+ patients – especially younger patients.

We are aware that since then a number of GP practices have had discussions in their teams about how to make their health services more LGBTQ+ accessible. We’ve also had a number of international enquiries about this work – including from Canada, New Zealand and Australia – who have been keen to use this work to increase awareness.

Thom has also been asked to adapt the factsheets for secondary care use in some parts of Scotland too. So, as expected, the theme seems to have resonated with a wide number of clinicians and service managers.

Thom and David recently caught up to discuss how these guidelines came about, and to explore some of the themes of why LGBTQ+ patients seem to face specific inequalities of access to health care – and how rural practice has some unique opportunities to improve this. We hope to have Thom back to this year’s RGPAS Conference (2-4 November, once again in Inverness – details soon) for an update on what how this work has been developing.

You can listen to the podcast here:

In the podcast above, we make reference to the work of Alex Bertie about recording his experience of seeking help and assistance with gender dysphoria. Alex’s videos make for some insightful and compelling viewing, but this one is specifically about his thoughts about the GP consultation – and the difference that a more supportive and informed consultation can make particularly at a challenging and difficult time.

One of the sessions at #ruralwonca was delivered by some of the team at the Journal for Remote & Rural Health. I was really sorry to miss it, due to presenting in another session, but my tweeted request to make the advice available online was answered quickly and the presentation is now available – see below.

The journal team are keen to encourage and motivate rural healthcare professionals to share their research, and seem genuinely interested in helping budding writers to put pen-to-paper or finger-to-keyboard.

There is a lot of great innovation and problem-solving going on in rural practice. Rural healthcare professionals tend to know their communities well, are used to dealing with limited resources, and some of the best examples of teamwork are to be found in rural settings. However ‘being academic‘ does not come easy to everyone, and the process of writing up evaluation and research can sometimes feel tedious and time-consuming.

However, it is now easier than ever to find interested journals, and there seems to be a drive to make the steps to getting work published more accessible.

Also, on the theme of research, here’s a great project that aims to enable rural doctors to develop their research activity through pragmatic and direct support. Delivered by the Faculty of Medicine at Memorial University in Newfoundland, it’s called the ‘6 for 6’ programme. Click here for more details or watch the video below.